Toronto health lawyer Omar Ha-Redeye says he welcomes the legislation, in the hope it will provide a potential boost to the development of individualized approaches to health care based on a patient’s genetic profile.

“We’re only just beginning to understand the complexity of the human genome, and it’s going to take us a couple of decades for us to fully get there. In the meantime, I would hate to see fallacious assumptions being made about genetic traits,” Ha-Redeye says.

However, the federal bill has raised the hackles of the insurance industry because of extra provisions that contemplate criminal sanctions in the enforcement of the ban on genetic discrimination.

Catastrophic impairment is a “hot topic”, to say the less, in the field of the accidents benefits and insurance companies. But, why is so important? Why is so polemic? We can resume to one main point, the money involve.

When a person is seeking to receive a benefit from an insurance company, being classified under the category of “catastrophic impairment” could represent a big difference in the amount of money that the person can receive from the insurance company.

Where we can find the definition of catastrophic impairment?

In Ontario, the Statutory Accident Benefits Schedule (SABS), define in his clauses 2(1.2)(f) and (g) what we can consider as a catastrophic impairment. Basically, the law define it as follow:

For the purposes of this Regulation, a catastrophic impairment caused by an accident is,

paraplegia or quadriplegia;

the amputation or other impairment causing the total and permanent loss of use of an arm or a leg;

a score of 9 or less on the Glasgow Coma Scale as published in Jennett, B. and Teasdale, G.,Management of Head Injuries, Contemporary Neurology Series, Volume 20, F.A. Davis Company, Philadelphia, 1981, according to a test administered within a reasonable period of time after the accident by a person trained for that purpose, or

a score of 2 (vegetative) or 3 (severe disability) on the Glasgow Outcome Scale, as published in Jennett, B. and Bond, M., Assessment of Outcome After Severe Brain Damage, Lancet i:480, 1975, according to a test administered more than six months after the accident by a person trained for that purpose;

subject to subsections (4), (5) and (6), an impairment or combination of impairments that, in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in 55 per cent or more impairment of the whole person; or

subject to subsections (4), (5) and (6), an impairment that, in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in a class 4 impairment (marked impairment) or class 5 impairment (extreme impairment) due to mental or behavioral disorder.

What about case law?

Being a main issue in the field of the accident benefits, is reasonable that exists a lot of case law related with what we can consider and we cannot consider as catastrophic impairment. We can mentioned two recent important cases related with the catastrophic impairment definition

Aviva and Pastore (2012 ONCA 642) : in this case, the Ontario Court of Appeal stated that is enough be markedly impaired in one of the four of her activities of daily living , social functioning, concentration and deterioration on the job, to the person be considered under the category of catastrophic impair and ask for a higher compensation.

Kusnierz v. The Economical Mutual Insurance (2010 ONSC 5749): in this case,Ontario Court of Appeal found that is possible combine psychological and physical impairments to reach the “minimum” percentage required to be consider as a case of catastrophic impairment.

The government directed consult with the medical community to amend the definition of catastrophic impairment as set out in the Statutory Accident Benefits Schedule, and to set out which need to be the qualifications and general requirements for health professionals who conduct catastrophic impairment evaluations.

What is next?

The definition of catastrophic impairment still will be a hot topic in the near future because involves economic issues and have a great impact in the insurance companies, who pressure the Ontario government to define and clarify the extent and limits of this concept, because certainty about this is important to both sides, companies and insured people. Is just a matter of time to see what direction is going to take this definition and how is going to impact the insurance industry.

Carlos Vera is a Paralegal student at Centennial College in Toronto studying professional communications with Omar Ha-Redeye.

There is a lot of confusion amongst drivers in Ontario as to how auto insurance rates are determined. Sometimes it may seem as though insurance providers randomly pluck numbers out of thin air; I myself have thought that when I receive my annual renewal notice. The truth is auto insurance is strictly regulated by the Financial Services Commission of Ontario (FSCO). Although each insurance provider has the flexibility to set their own rates based on a number of criteria, the Superintendent of Financial Services must review and approve any changes.

Protecting consumers by strengthening the prohibition on the use of credit scoring, delays and other questionable screening techniques when providing quotes

Streamlining a number of processes to reduce transaction costs and ensure more accident benefit dollars go to treating accident victims

Auto Insurance Fraud

A major contributor to rising auto insurance rates is the prevalence of fraud. In order to address this issue, the government announced the creation of an Auto Insurance Anti-Fraud Task Force in its 2011 Budget. In November 2012 the group submitted their recommendations and in January 2013 the government took action.

Requiring insurers to provide claimants with all reasons for denying a claim

Giving claimants a bi-monthly, detailed statement of benefits paid out on their behalf

Requiring claimants to confirm attendance at health clinics

Making providers subject to sanctions for overcharging insurers for goods and services

Banning providers from asking consumers to sign blank claims forms

Now What?

The government continues to stand by its promise to reduce auto insurance rates by tackling fraud, reducing costs, and implementing legislative changes. I commend them for following through on this initiative, but I will only be able to confirm its effects when I see my own auto insurance policy renewal in the fall.

Farrah Rajan is a Paralegal student at Centennial College in Toronto studying professional communications with Omar Ha-Redeye.

With the rising costs of health care, and the growing demographics of baby boomers, health administrators are always looking for savings. A new and provocative study out of the Indiana University suggests that computer modelling can choose better and less-expensive treatments than the physicians alone, resulting in a 50% reduction in costs and 40% increase in patient outcomes.

By using a new framework that employs sequential decision-making, the previous single-decision research can be expanded into models that simulate numerous alternative treatment paths out into the future; maintain beliefs about patient health status over time even when measurements are unavailable or uncertain; and continually plan/re-plan as new information becomes available. In other words, it can “think like a doctor.”

Although Derrick Harris at Digacom states that nobody is suggesting we replace physicians with computers, he does point out other advances in this area:

IBM has been banging this drum loudly, most recently with two new commercial versions of its Watson system — one of which is designed to determine the best-possible course of treatment for lung cancer patient by analyzing their situations against a library of millions of pages of clinical evidence and medical research.

On February 23, 2012, Toronto Police arrested 37 individuals in connection with an insurance scam. The operation, called Project Whiplash, targeted a group that allegedly staged 77 motor vehicle collisions.

This week the ringleader of the operation, Uthayakanthan Thirunavukkarasu, was sent to prison for 3.5 years and was ordered to pay restitution of $375,000. An estimated $1.2 million flowed through his account for the scam.

At least one of the staged crashes in May 2007 resulted in a brain injury.

Josh Tapper and Wendy Gillis of the Toronto Star explained how the scam worked:

A recruiter might scope possible participants inside a public space, like a coffee shop, insisting the plan is foolproof, an easy way to earn money. From there, the recruiter acts as coach. He tells people where the accident will occur, where inside the vehicle they should sit and what to tell authorities following the crash…

While police say that numerous collisions allegedly submitted for insurance claims did not actually occur, those that did were also planned carefully. In one collision racket, a scheming driver might stop in front of a laneway and motion an oncoming vehicle to enter traffic; his partner, driving in the opposite lane, then “accidentally” collides with the car… emergency personnel are sometimes called to make the scene more realistic.

With a police investigation underway, the scammers would allegedly forge medical documents claiming injury, often signing on behalf of doctors who never actually assessed the patients. Some of the accused are identified as paralegals, who allegedly filed the insurance claims seeking financial recovery for vehicle damage, physiotherapy, chiropractic work and lost wages.

Insurance companies have decried the practice of staged collisions as one of the reasons for higher premium rates.

About This Site

Canadian Health Law contains updates and articles about the intersection of health and law in Canada. It is written and edited entirely by professionals who work in this area.
The site is edited by Omar Ha-Redeye.
For any comments or concerns, please email him at Omar at FleetStreetLaw dot Com.

Contributors

Alexander Rozine is an associate at Barapp Law, a personal injury firm located in Toronto.

John Greiss obtained his pharmacy and law degrees at the University of Alberta. His current interests surround pharmaceutical and healthcare law in Ontario and Canada.